Robot-assisted thoracoscopic right superior lobectomy with conversion for controlled bleeding: a complex case

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2015-02-13

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As the technique and the indications of robotic video-assisted lung resections have evolved, surgeons have had to face numerous pitfalls. One in particular is the vascular tear, which urge the operator to convert to thoracotomy. The decision as to when and how to convert to thoracotomy is always difficult to make. This video illustrates a complex case of robotic right upper lobectomy which required thoracotomy for controlled bleeding.
This is the case of a 47-year-old woman with a past medical history of severe chronic obstructive pulmonary disease, active smoking, alcoholic liver cirrhosis, but no history of tuberculosis. She presented with a 3-month history of a right upper lobar mass detected on chest X-ray which evolved despite antibiotic treatment. Work-up including a PET-scan evoked a suspicion of malignancy.
While finishing the lobectomy, we had to face a difficult dissection of the posterior part of the oblique fissure with a tricky control of the dorsal artery. Trying to open the fissure with the endostapler, we tore the arterial branch and applied an immediate control by means of a double Cadiere grasper. When bleeding was finally controlled, we decided to convert for safety reasons. We proceeded without undocking the last robotic arm, clamping the artery until control was achieved using thoracotomy instruments. It allowed us to manage this situation with no rush and stress.
There are two types of bleeding: controlled and uncontrolled. In our experience of RATS lobectomy and by reviewing our complications, we feel that there are several advantages to this technique: first, small instruments make small injuries which can be controlled by robotic instrument. Secondly, passive locking of the robotic arm provides sufficient time for the surgical team to prepare conversion.